Though Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) does not recognize this as an official category, internet game addiction (IGD) is becoming a serious problem in countries which have wide access to the internet.[1,2] DSM-5 presently proposes and encourages further research into this disorder before committing to it and defines it under section III.[3] Conceptually, the gamut of internet addiction (IA) has been proposed on lines of substance abuse, with negative effects on socio-occupational functioning,[1] and found to cause changes in brain regions akin to chemical dependence.[2] Though motivational enhancement therapy (MET) remains a cornerstone for treatment of drug addiction, its applications in IA and IGD have been sparse. The purpose of this report was to describe a pilot intervention using MET-cognitive behavior therapy (CBT) principles to treat IGD in an adolescent.

Index patient Master D.R., a 14-year-old boy, younger of the two siblings, with nil contributory past, family and personal history; easy going premorbid temperament; was brought by his parents with complaints regarding his negative attitude, depression, and overuse of internet for 2 years. The problems have started when his elder sister met with an accident and was admitted to the hospital. Patient was left alone at home as his parents busied themselves with her care, and he started playing internet games to overcome this loneliness. He started enjoying these games and time spent on games increased gradually, with consequent deterioration in social and peer relationships, studies and attitude toward his parents. He started skipping school, spending money at internet parlors and on buying games. As his parents became aware of it and confronted him, patient expressed his frustration with the situation, and desire to reduce the hours. However, he reported an inability, in spite of repeated attempts, to control his behavior and continued spending around 3–5 h on playing games on weekdays and up to 13 h on weekends.

Our baseline assessment revealed an average IQ. ESDST, BVMGT, and TAT were administered which revealed adequate attention, concentration, and visuomotor coordination. There was conflict with authority figures and needs were aggression and achievement. Main emotions were guilt, sadness, and anger. IA Test (IAT) score[4] was 83.

Initial therapy sessions consisted of rapport building with patient, detailed interview, and primary case formulation. At this point, he was at contemplation stage of motivation. Subsequent sessions were held in an empathetic atmosphere, with emphasis on patient’s psycho-education and cost-benefit analysis of the behavior. His level of motivation improved to “preparation” stage. As the urge for gamming was accompanied with physiological and emotional arousal, Jacobson’s progressive muscle relaxation was initiated. Further sessions focused on assessment of game addiction and creating a contract for behavior modification. Patient agreed to try to reduce the time spent on games and increase on other healthy activities. The contract was in written form and signed by patient, his mother, and therapist; and tokens were introduced as positive reinforcement. As sessions progressed, he began spending less time on weekdays, but continued with excess on weekends, and the later did not respond satisfactorily.

Patient was next encouraged to be conscious of how his time was spent more on games than intended, and of thoughts, emotions and behaviors (TE and B) contributing to this. He was asked to record his TE and B related to games in a format. Major determinant was found to be boredom. In subsequent sessions, he was given two pieces of paper every week: One for recording his activities and time, another for recording his TE and B related to games. The main issue for him was managing his boredom. Based on his suggestion, it was agreed upon that if he drew cartoons instead of playing games, he would be allowed to ride scooty (reinforcer) for 1 h. There was improvement, and therapy was terminated when gains had consolidated. He appeared for his exams and scored quite well. He reduced his time on playing online games even on weekends, and IAT score came down to 48.

There are not many studies for intervention of IGD. In our case, IGD began in response to the relative neglect of the child and the consequent boredom, and was consolidated by subsequent negative reinforcements. We emphasize on varied antecedents and consequences for development of IGD, like in our case, and on their adequate assessment to plan individual interventions. Given the still-shrouded nature of this disorder, there is no available guideline on management. Our report discusses an interesting application of the tested MET-CBT principles in ameliorating IGD.